COLORECTAL SURGERY ENHANCED RECOVERY PROGRAMME - Draft Guidelines

5th Draft Guidelines Enhanced Recovery Programme April 07

COLORECTAL SURGERY

ENHANCED RECOVERY PROGRAMME

DRAFT GUIDELINES

Version Date Purpose of Issue/Description of Change Review Date
1 Oct 06 April 08
Scope
Author Approved by Date
Margaret Jennings
Colorectal Specialist
Nurse

6TH Draft Guidelines Enhanced Recovery Programme April 07

CONTENTS

1. INTRODUCTION............................................................................................. 1
1.1. SUMMARY ........................................................................................... 1
1.2. BACKGROUND AND RATIONALE ...................................................... 1

2. PREOPERATIVE INFORMATION .................................................................. 2

3. PERIOPERATIVE ........................................................................................... 3

4. POSTOPERATIVE.......................................................................................... 4

5. DISCHARGE ................................................................................................... 4

6. CONCLUSION ................................................................................................ 5

7. REFERENCES................................................................................................ 6

APPENDIX 1 - ENHANCED RECOVERY PROGRAMME COLORECTAL SURGERY
8

APPENDIX 2 - PROTOCOL FOR THE USE OF NUTRICIA PRE-OP..................... 11

APPENDIX 3 - OCCUPATIONAL THERAPY.......................................................... 14

APPENDIX 4 EPIDURALS FOR PAIN RELIEF ................................................... 14

APPENDIX 5 ENHANCED RECOVERY PROGRAMME............................... 28

APPENDIX 6 .34

APPENDIX 7 - PONV FLOW CHART ..................................................................... 35


COLORECTAL SURGERY ENHANCED RECOVERY PROGRAM

1. INTRODUCTION

1.1. SUMMARY

This document provides guidelines to support the implementation of the enhanced
recovery program at Harrogate District Hospital for patients receiving elective
colorectal cancer surgery.

The aim is to improve patient recovery after surgery and reduce morbidity; such
programs enable the patient to be discharged home earlier, without compromising
the patients safety and wellbeing

1.2. BACKGROUND AND RATIONALE

A recent development in elective large bowel surgery is the introduction of the
enhanced recovery program, also referred to as fast track (Wilmore D; Kehlet H
2005).

The enhanced recovery program combines a number of elements, aimed at
enhancing patient recovery, and reducing the stress response after surgery, aiding
faster recovery and shorter hospital stay (Basse L et al 2000; Kehlet et al 2000).

The Enhanced Recovery Program was introduced over a decade ago with
favourable early results, based on solid evidence derived from randomized trials
(Kehlet H 2005)

The main elements to this are

· Extensive pre operative counselling
· Bowel preparation. There will be no mechanical bowel preparation. If an on
table colonoscopy is required then this will be highlighted in pre assessment ,
as to the need for picoloax
· No pre-medication
· Avoid preoperative fasting but carbohydrate loaded drinks until 2 hours
before surgery (Type 1 and 2 diabetics excluded)
· Low residue diet 3 days prior to surgery
· Tailored anaesthetics, involving thoracic epidural anaesthesia and reduced
intra operative fluids
· Perioperative high inspired oxygen concentrations
· Avoidance of perioperative fluid overload/ reduced post operative fluids
· Tailored abdominal incisions
· Non opiod pain management ie only use opiod as a rescue (refer to
guidelines)
· Avoid routine use of drains, remove early if used

Version 1 Page 1 of 35 Review Date April 08


· Avoidance of naso-gastric tubes
· Enforced post-operative mobilisation (see appendix .)
· Early removal of bladder catheters
· Standard laxatives and prokinetics
· Early postoperative feeding

The Enhanced Recovery Program requires a team approach from Surgeons,
Anaesthetists, Pharmacists, Physiotherapist, Occupational Therapist, Dieticians,
Nursing staff and services allied to health in primary care, each will play a vital role in
achieving the aims of the program

2. PREOPERATIVE INFORMATION

Pre surgery information is crucial in ones assessment of the patient prior to surgery
as problems/concerns addressed in this period can reduce the barriers that often
delay patient discharge (see appendix 2) The principles that require engagement at
this point are the principles of supportive care and include:

· Information needs of patients and carers; patients and their carers will be
given information on post operative goals i.e. when what will happen, e.g.
what will happen on the evening after surgery, what will happen on day
1,2,3,4,etc (see appendix 4)
· Being treated with respect
· Empowerment
· Having choices
· Equal access
· Continuity of care
· Meeting physical/psychological/social/spiritual needs
· Risk assessment for when discharged, preventing possible barriers to
optimisation

These principles have been shown to improve patient compliance with enhanced
rehabilitation, reduce anxiety, pain and post operative ileus, and have an important
impact on early recovery, and reduced length of hospital stay (Monagle J et al 2003)

Within this period a pre-operative assessment, an environment of multidisciplinary
team working, patients are assessed with regard suitability for optimization. The pre
operative assessment in the context of the enhanced recovery program has two
major functions;

1. To recognise preoperative comorbidity, and therefore optimise these
conditions

2. Detect other factors, including social and psychological , that may cause a
barrier to early recovery and discharge



Patients at risk of having a stoma as a result of their surgery will require to be seen
by the stoma care sister to be assessed and arrangements made for Pre operative
stoma education, as not being proficient in stoma management can delay discharge

There is evidence that avoiding picolax preparation, prior to surgery, reduces
electrolyte imbalances and dehydration This has been reported as avoiding
electrolyte imbalances and dehydration, (Beloosesky Y et al 2003).There has been
no reported increase in anastomotic leaks and septic complications by not giving
bowel prep pre operatively (Guenaga K F et al 2003; Zmora O et al 2003).

It has been agreed by the Colorectal surgeons that prior to colonic or rectal
resection, patients will receive a phosphate enema 2 hours pre operatively. This may
well be an interim measure, and may change in the future when an agreed bowel
preparation protocol has been agreed as part of the enhanced recovery program

The patient will receive Preop nutritional supplements (see appendix 1) Oral
carbohydrate loading has been shown to reduce less postoperative insulin
resistance and improved outcomes after surgery (Ljungqvist O, Nygren J 2002).
Patients who are Type 1 and 2 diabetics will be excluded from pre op nutricia.

3. PERIOPERATIVE

Within this period the patient will receive:

High inspired oxygen. This has been shown to increase intestinal intramural
oxygenation (Ratnaraj J et al 2004), less risk of wound infection (Grief R et al 2000),
and less post operative nausea and vomiting (Grief R et al 1999).

Avoid post operative nausea and vomiting (see appendix 5) It is difficult to determine
the relevance of nausea and vomiting to overall outcomes measures in colorectal
surgery, however in the context of the enhanced recovery program nausea and
vomiting may increase postoperative stress and discomfort and therefore become a
barrier to the recovery process. A multi modal approach to care is therefore
important and needs to be included in ones strategy so that optimisation is achieved.

Decision on surgical incision will be made by the surgeon, but a Transverse Incision
for a Right Hemicolectomy has been shown to give the patient less pain, fewer chest
infections (Lindgren PG et al 2001; Grantcharov TP, Rosenburg J 2001); encourages
earlier gut function and feeding, earlier mobilisation resulting in a shorter hospital
stay (Kam MH et al 2004; Donati D et al 2002).

· Epidural anaesthesia

Epidural analgesia is an effective way of treating pain. It is important that patients
have confidence in this technique. Patients will receive information pre-operatively
on what to expect and this will be supported in the post-operative period by the
caring team (see appendix 3)



It is important that all members of the caring team have a full understanding of
epidural analgesia enabling for effective management. This guidance is supported by
the Clinical Practice Guidelines for Epidural Analgesia for Adult Acute pain
Management (HDFT 2006)

· Post epidural management

Refer to the clinical practice guidelines for Epidural analgesia for adult acute pain
management (HDFT 2006), see appendix 4

· Intravenous fluids

Intravenous fluids at an appropriate rate will be given, adjusted to oral intake, fluid
loss from stoma, urine output, vital sign recordings, of blood pressure, pulse, central
venous pressure, blood biochemistry i.e. Urea and Electrolytes
(U+Es), and how the patient is clinically. If the patient has an epidural refer to Clinical
practice guidelines (HDFT 2006)

· Drains/Naso- gastric tubes

Drains and nasogastric tubes will be avoided, as there is no evidence of their
benefit of use (Merad F et al 1999; Cheatham ML et al 1995), only that they
decrease mobilisation and increase patients distress (Hoffmann S et al 2001).

4. POSTOPERATIVE

The aim is to introduce fluid and diet early. This has been shown to be safe
(Reissman P et al 1995) resulting in fewer septic complications (Beier-Holgersen R,
Boesby S 1998).

· Enhanced mobility plan.

Early mobilisation has been shown to reduce the incidence of post operative ileus,
and shorter hospital stay (Basse L et al 2002).

5. DISCHARGE

There will be planned goals for each day (see appendix 5)
Target discharge dates for the following are:

Right Hemicolectomy 5days
Left Hemicolectomy 7 days
Sigmoid Colectomy 5 days
Anterior resection with stoma 7days
Abdomino perineal resection 10 days
Anterior resection 5 days



Outcome measures with regard physiological function, psychological function, gut
function and clinical outcome will need to be considered when evaluating this service
long term

6. CONCLUSION

The enhanced recovery program requires multidisciplinary team work. Evidence
shows that the best and most cost effective outcomes for patients are achieved
when professionals work together and generate innovation to ensure progress in
practice and service (DOH 1993).



7. REFERENCES

BASSE L, HJORT JAKOBSON D ET AL. A clinical pathway to accelerate recovery
after colonic resection. Ann Surg 2000: 232: 51-57

BASSE L, RASKOV HH ET AL. Accelerated postoperative recovery programme after
colonic resection improves physical performance, pulmonary function and body
composition. Br J Surg 2002;89: 446-453

BASSE L, THORBOL J E.ET al. Colonic surgery with accelerated rehabilitation or
conventional care. Dis Colon Rectum 2004; 47:271-278.

BEIR-HOLGERSEN R, BOESBY S. Effect of early postoperative enteral nutrition on
postoperative infections. Ugeskr Laeger 1998; 160: 3223-3226

BELOOSESKY Y, GRINBALT J ET AL. Electrolyte disorders following oral sodium
phosphate administration for bowel cleansing in elderly patients. Arch intern Med
2003; 163: 803-808

CHEATHAM M L, CHAPMAN W C ET AL. A meta analysis of selective versus
routine nasogastric decompression after elective laparotomy. Ann Surg 1995; 221:
469-476

DONATI D, BROWN S R ET AL. Comparison between midline incision and limited
right skin crease incision for right sided colonic cancers. Tech Coloproctol 2002; 6:
1-4

GRIEF R, AKCA O ET AL. Supplemental perioperative oxygen to reduce the
incidence of surgical wound infection. Outcomes Research Group. N Engl J Med
2000; 342: 161-167

GRIEF R, LACINY S ET AL. Supplemental oxygen reduces the incidence of post
operative nausea and vomiting. Anesthesiology 1999; 91: 1246-1252

GUENAGA KF, MATOS D, CASTRO AA ET AL. Mechanical bowel preparation for
elective colorectal surgery. Cochrane database Syst Rev 2003; (2) CDOO1544

HOFFMANN S, KOLLER M ET AL. Nasogastric tube versus gastrostomy tube for
gastric decompression in abdominal surgery: a prospective, randomized trial
comparing patients tube-related inconvenience. Langenbecks Arch Surg 2001; 386:
402-409.

KAM M H,SEOW-CHOEN F ET AL. Minilaparotomy left iliac fossa skin crease
incision vs midline incision for left sided colon cancer. Tech Coloproctol 2004;8: 85-
88

KEHLET H, DAHL J B. Anaesthesia, surgery, and challenges in postoperative
recovery. Lancet 2003; 362: 1921-1928



KEHLET H, WILMORE D W.. Multimodal strategies to improve surgical outcome. Am
J Surg 2002; 183: 630-641.

KEHLET H, WILMORE D W. Fast track surgery. Br J Surg 2005; 92: 3-4

LINDGREN P G, NORDGREN S R ET AL. Midline or transverse abdominal incision
for right sided colon cancer-a randomized trial. Colorectal Dis 2001;3: 46-50

LJUNGQUIST O, NYGREN J, THORELL A. Modulation of post-operative insulin
resistance by pre-operative carbohydrate loading. Proc Nutr Soc 2002; 61: 329-336.

MERAD F, HAY J M ET AL. Is prophylactic pelvic drainage useful after elective
rectal or anal anastomosis? A multicenter controlled randomized trial. French
Association for Surgical Research. Surgery 1999; 125: 529-535

MONAGLE J ET AL 2003. ANZ J Surg 2003

RATNARAJ J, KABON B ET AL. Supplemental oxygen and carbon dioxide each
increase subcutaneous and intestinal intramural oxygenation. Anesth Analg 2004;
99: 207-211

WILMORE DW, KEHLET H. Recent advances: management of patients in fast track
surgery. BMJ 2001; 322: 473-476

ZMORA O, MAHAJNA A, ET AL. Colon and rectal surgery without mechanical bowel
preparation: a randomized prospective trial. Ann Surg 2003; 237: 363-367



APPENDIX 1 - ENHANCED RECOVERY PROGRAMME COLORECTAL SURGERY

Dietary Management Low Fibre Diet and Pre Op Nutritional Supplement

Three days before surgery you should eat a low fibre diet. This reduces the
stool residue in the bowel.

The main sources of fibre in the diet are cereal products, vegetables and fruits.
When following a low fibre diet, intake of these foods needs to be reduced. It
is important to have regular meals and a varied diet which includes foods such as
meat, poultry, fish, eggs and dairy products (milk, cheese, yoghurt).

It is important to have a good fluid intake ie at least 8-10 cups (water, tea,
squash etc) per day.

Foods to avoid Foods to use instead
Wholemeal, granary, hi-bran and White bread
brown breads White flour
Wholemeal flour Pastry (white flour)
Wholemeal pastry
Wholegrain breakfast cereals eg Corn and rice breakfast cereals
Weetabix, Shreddies, eg Corn Flakes, Rice Krispies
Branflakes, muesli, porridge,
natural bran
Brown rice White rice
Wholewheat pasta White and tricolour pasta
Wholegrain biscuits eg digestive, Biscuits made with white flour
Hob Nobs, flapjack, bran eg rich tea, custard creams,
biscuits fig rolls crispbreads, shortbreads, cream crackers,
oatcakes butter puffs
Fruit cakes Cake made with white flour eg
Mince pies sponge,
Jam tarts (use jelly jams, lemon
curd fillings)
Dried fruit (including tinned Fresh, peeled fruit
prunes) Tinned fruit
Seeds & pips (Maximum of 2 portions/day)
Nuts Fruit juice (as desired)



Milk puddings, stewed apple and
Desserts eg
Sponge & pies made with fruit custard, apple pie, sponge
containing skins and pips, eg pudding and custard
plums, gooseberries and Mousses, plain or set yoghurts,
raspberries jelly
Jelly jams and marmalade
Preserves
Jams and marmalade containing Lemon curd
a high fruit content and/or Honey
seeds and pips Marmite
Mincemeat
Peanut butter

The day before your operation you will be advised to have clear fluids and Pre
Op nutritional drinks.

Pre Op is a clear, lemon flavoured carbohydrate drink. It has been specifically
designed for patients who are scheduled to have bowel surgery.

Taking these drinks has been shown to benefit patients recovery from surgery.
They have been shown to improve well-being and may contribute to a reduction
in length of hospital stay.

In pre-assessment clinic or on the ward you will receive 4 cartons to take the
evening before surgery. These will be given at 4.00 pm, 6.00 pm, 8.00 pm and
10.00 pm.

On the day of surgery you will receive 2 more cartons to drink on the ward.
These should be fully consumed 2 hours prior to you having your anaesthetic.

Pre Op should be sipped slowly and is best served chilled.

After surgery, you should return to your usual diet unless advised otherwise by
the Dietitian, Nurse Specialist or Consultant.

If you have any questions, please contact:-
Margaret Jennings Jill Gale/Heidi Cobb
Colorectal Clinical Nurse Specialist or Specialist Dietitians
Harrogate District Hospital Harrogate District Hospital
( (01423) 553340 ( (01423) 553329

Produced by: Nutrition and Dietetic Service, Harrogate District Hospital - March 2007



Review date: March 2008



APPENDIX 2 - PROTOCOL FOR THE USE OF NUTRICIA PRE-OP

INTRODUCTION

Recovery after major surgery is significantly delayed by the development of temporary insulin
resistance, which is associated with muscle weakness and wasting (1).
Recent evidence has suggested that post-operative insulin resistance and the stress response to
major abdominal surgery can be significantly attenuated by pre-operative carbohydrate loading (2-5).
A carbohydrate drink, Nutricia preOp has been developed specifically for this purpose, in order to
provide a sustained hyperinsulinaemia (required to prevent insulin resistance) while ensuring rapid
gastric transit (making it safe to take up to 2 hours before induction of anaesthesia) (6).
This treatment has been shown to reduce post-operative loss of muscle mass (7) and improve well
being (8).
Pre-operative oral carbohydrate loading has been incorporated into enhanced recovery programmes
for major abdominal surgery in several European countries.
The recommended intake of Nutricia preOp ensures that at the time of surgery the patient is in an
anabolic, rather than catabolic state, has loaded glycogen stores and an empty stomach.

The product is contraindicated for use in emergency surgery, if a patient has delayed gastric
emptying (patients with delayed gastric emptying will be identified by the consultant) and Type 1 and
2 Diabetics.

The regimen has patient benefits, e.g. less thirst, hunger and anxiety before the operation and may
contribute to a reduction in length of hospital stay.

PURPOSE OF THE PROTOCOL

The purpose of this protocol is to ensure that all patients admitted for elective colorectal resections
(unless contra-indicated) will receive a carbohydrate drink (Nutricia preOp) up to 2 hours prior to the
anaesthetic being administered.

DEFINITIONS

Nutricia preOp is a clear, non-carbonated, lemon flavoured, iso-osmolar carbohydrate drink which
provides a sustained hyperinsulinaemia while ensuring rapid gastric transit.
Each carton contains 200ml, 100 calories, 25g carbohydrate and electrolytes.
It is fat, protein, lactose, gluten and fibre free.
It is a drink for the medical purpose of pre-operative dietary management of lower gastrointestinal
surgical patients.

ADMINISTRATION

The initial loading dose is 4 x 200ml the evening before surgery.
The final dose is 2 x 200ml to be fully consumed two hours prior to anaesthesia.

The dose should be written on the drug chart by the pharmacist in pre-assessment clinic.
Every patient will be given an information leaflet and will consent to this part of their surgical pathway.



FLOW CHART FOR THE USE OF NUTRICIA PRE-OP

Lower GI patient identified by consultant, pharmacist or nursing staff
in pre-assessment unit as a candidate for preOp. (Colorectal Nurse
Specialist will already be aware of patient and will discuss with the
dietitian).

Pharmacist writes patient up for preOp drinks on the drug chart (4 x 200ml evening
before surgery, and 2 x 200ml to be fully consumed two hours pre anaesthesia)
Cartons given to patient to take home.

Information leaflet given to patient to explain rationale for treatment and
directions for use.
(Leaflet Patient given contact number for CNS and dietitians in case of queries.

Patient admitted for surgery.

CNS marks patient as receiving preOp on colorectal patient database.

Patient takes second dose on
ward.

Protocol to be reviewed/ audited after six months



REFERENCES

1. Insulin resistance: a marker of surgical stress. Thorell A, Nygren J, Ljungqvist O.
Curr Opin Clin Nutr Metab Care. 1999 Jan:2(1):69-78

2. Randomised clinical trial of the effects of immediate enteral nutrition on metabolic responses to
major colorectal surgery in an enhanced recovery protocol. Soop M et al
Br J Surg 2004 Sept;91: 1138-1145

3. Preoperative oral carbohydrate treatment attenuates immediate post operative insulin resistance.
Soop M et al.
Am J Physiol Endocrinol Metab. 2001 April; 280(4):E576-583

4. Preoperative oral carbohydrate administration reduces postoperative insulin resistance. Nygren J et
al.
Clin Nutr 1998 April;17(2):65-71

5. Can post traumatic insulin resistance be attenuated by prior glucose loading? Byrne CR, Carlson
GL.
Nutrition 2001;17:354-355

6. Preoperative gastric emptying. Effects of anxiety and oral carbohydrate administration. Nygren J et
al.
Ann Surg 1995 Dec;222(6):728-734

7.The administration of an oral carbohydrate containing fluid prior to major elective upper
gastrointestinal surgery preserves skeletal muscle mass post operatively a randomised clinical trial.
Yuill KA et al
Clin Nutr 2005 Feb;24(1):32-37

8. Randomised clinical trial of the effects of oral preoperative carbohydrates on post operative nausea
and vomiting after laparoscopic cholecystectomy. Hausel J et al.
Br J Surg. 2005 Feb 28 (E pub)

Jill Gale and Heidi Cobb
Specialist Dietitians
September 2006

With acknowledgement to Kirstine Farrer, Consultant Dietitian, Salford Royal Hospitals NHS
Trust



APPENDIX 3 - OCCUPATIONAL THERAPY

Pre Surgery Information

Occupational Therapists (OTs) work as part of the team on the ward. We
aimtoh elp you to become as independent as possible with all the tasks that
you need to do during the day such as personal care. In order to help us plan
the treatement that you require, enabling you to return home as quickly, safely
and independently as possible, please complete the following questionnaire
which the OT will then discuss with you whilst you are on the ward.

Social Information

1. What type of accommodation do you have? (house, flat, bungalow)

2. Is this privately owned/council/rented?

3. Describe the access to your property. (steps? rails?)

4. Do you have a toilet upstairs/downstairs/both?

5. Do you have any stairs to go up and if so, as you are going upstairs is the rail
on the left/right/both sides?

6. If necessary do you have a spare bed and would there be room to have it
downstairs?

7. Do you live alone or if not, who do you live with?

8. Is the person you live with reasonably fit?



9. Do you have any formal support at present?
(Homecare/Meals on Wheels/Cleaner?)

l0. Do you have any informal support? (Family/Friends) Can you describe how (if
at all) they help you with everyday activities?

11. Please describe your current level of mobility. Do you use a walking aid?

12. Please describe how you currently manage personal and domestic tasks.
(washing, dressing, cooking, housework, shopping)

13. Do you have any difficulty getting on or off you bed, chair or toilet?

14. Where do you eat your meals?

15. Do you have any equipment that helps you with everyday tasks?
(raised toilet seat, commode, kitchen stool, trolley, helping hand)

16. Do you have any concerns about managing at home following your
operation?

Thank you for completing this questionnaire.



APPENDIX 4 EPIDURALS FOR PAIN RELIEF

Epidurals for pain
relief after surgery

This leaflet is for anyone who may benefit
from an epidural for pain relief after
surgery. We hope it will help you to ask
questions and direct you to sources of
further information.



This booklet explains what to expect when you have an
epidural anaesthetic for pain relief after your operation.
It is part of a series about anaesthetics and related topics
written by a partnership of patient representatives, patients and
anaesthetists. You can find more information in other leaflets in
the series.
You can get these leaflets, and large print copies, from
www.youranaesthetic.info. They may also be available from the
anaesthetic department in your hospital.
The series will include the following:

l Anaesthesia explained
l You and your anaesthetic (a summary of the above)
l Your child s general anaesthetic
l Your spinal anaesthetic
l Headache after an epidural or spinal anaesthetic
l Your child's general anaesthetic for dental treatment
l Local anaesthesia for your eye operation
l Your tonsillectomy as day surgery
l Your anaesthetic for aortic surgery
l Anaesthetic choices for hip and knee replacement

Throughout this booklet we use these symbols
To highlight your options or choices.
To highlight where you may want to take a particular action.
To point you to more information.



Introduction

This leaflet describes what happens when you have an
epidural, together with any side effects and complications that
can occur. It aims to help you and your anaesthetist make a
choice about the best method of pain relief for you after your
surgery.
What is an epidural?

The nerves from your spine to your lower body pass through an
area in your back close to your spine, called the quot;epidural
spacequot;.

l To establish an epidural an anaesthetist injects local
anaesthetics through a fine plastic tube called an epidural
catheter into this epidural space.. As a result, the nerve
messages are blocked. This causes numbness, which varies
in extent according to the amount of local anaesthetic
injected.
l An epidural pump allows local anaesthetic to be given
continuously.
l Other pain relieving drugs can also be added in small
quantities.
l The amounts of drugs given are carefully controlled.
l You may be able to press a button to give a small extra dose
from the pump. Your anaesthetist will set the pump to limit
the dose which you can give, so overdose is extremely rare.
l When the epidural is stopped, full feeling will return.
l Epidurals may be used during and/or after surgery for pain
relief.



How is an epidural done?

Epidurals can be put in:
l when you are conscious
l when you are under sedation (when you have been given a
drug which will make you drowsy and relaxed, but still
conscious)
l or during a general anaesthetic.

These choices can be discussed further with your anaesthetist.
1. A needle will be used to put a thin plastic tube (a cannula )
into a vein in your hand or arm for giving fluids (a drip ).
2. If you are conscious, you will be asked to sit up or lie on your
side, bending forwards to curve your back. It is important to
keep still while the epidural is put in.
3. Local anaesthetic is injected into a small area of the skin of
your back.
4. A special epidural needle is pushed through this numb area
and a thin plastic catheter is passed through the needle into
your epidural space. The needle is then removed, leaving
only the catheter in your back.

Your epidural



What will I feel?
l The local anaesthetic stings briefly, but usually allows an
almost painless procedure.
l It is common to feel slight discomfort in your back as the
catheter is inserted.
l Occasionally, an electric shock-like sensation or pain occurs
during needle or catheter insertion. If this happens, you must
tell your anaesthetist immediately.
l A sensation of warmth and numbness gradually develops,
like the sensation after a dental anaesthetic injection. You
may still be able to feel touch, pressure and movement.
l Your legs feel heavy and become increasingly difficult to
move.
l You may only notice these effects for the first time when you
recover consciousness after the operation, particularly if your
epidural was put in when you were anaesthetised.
l Overall, most people do not find these sensations to be
unpleasant, just a bit strange.
l The degree of numbness and weakness gradually decreases
over the first day after the operation.
What are the benefits?
l Better pain relief than other methods, particularly when you
move.
l Reduced complications of major surgery, e.g.
nausea/vomiting, leg/lung blood clots, chest infections, blood
transfusions, delayed bowel function.
l Quicker return to eating, drinking and full movement, possibly
with a shorter stay in hospital compared to other methods of
pain relief.
How do the nurses look after me on the ward with an
epidural?



l At regular intervals, the nurses will take your pulse and blood
pressure and ask you about your pain and how you are
feeling.
l They may adjust the epidural pump and treat side effects.
l They will check that the pump is functioning correctly. They
will encourage you to move, eat and drink, according to the
surgeon s instructions.
l The Pain Relief Team doctors and nurses may also visit you,
to check your epidural is working properly.
When will the epidural be stopped?
l The epidural will be stopped when you no longer require it for
pain relief.
l The amount of pain relieving drug being given by the epidural
pump will be gradually reduced.
l A few hours after the pump is stopped, the epidural tubing will
be removed, as long as you are still comfortable.
l The epidural catheter will be removed if it is not working
properly. Another epidural catheter can be re-inserted if
necessary.
Can anyone have an epidural?
No. An epidural may not always be possible if the risk of
complications is too high.
The anaesthetist will ask you if:
l you are taking blood thinning drugs, such as warfarin
l you have a blood clotting abnormality
l you have an allergy to local anaesthetics
l you have severe arthritis or deformity of the spine
l you have an infection in your back



Side effects and complications

l All the side effects and complications described can occur
without an epidural.
l Side effects are common, are often minor and are usually
easy to treat. Serious complications are fortunately rare.
l For major surgery, the risk of permanent nerve damage is
probably about the same, with or without an epidural.
l The risk of complications should be balanced against the
benefits and compared with alternative methods of pain relief.
Your anaesthetist can help you do this.



Very common or common side effects and
complications
Inability to pass urine. The epidural affects the nerves that
supply the bladder, so a catheter ( tube ) will usually have to be
inserted to drain it. This is often necessary anyway after major
surgery to check kidney function. With an epidural, it is a
painless procedure.
Bladder function returns to normal when the epidural wears off.
Low blood pressure. The local anaesthetic affects the nerves
going to your blood vessels, so blood pressure always drops a
little. Fluids and/or drugs can be put into your drip to treat this.
Low blood pressure is common after surgery, even without an
epidural.
Itching. This can occur as a side effect of morphine-like drugs
used in combination with local anaesthetic. It is easily treated
with anti-allergy drugs.
Feeling sick and vomiting. These can be treated with anti-
sickness drugs. These problems are less frequent with an
epidural than with most other methods of pain relief.
Backache. This is common after surgery, with or without an
epidural and is often caused by lying on a firm flat operating
table.
Inadequate pain relief. It may be impossible to place the
epidural catheter, the local anaesthetic may not spread
adequately to cover the whole surgical area, or the catheter can
fall out. Overall, epidurals usually provide better pain relief than
other techniques. Other methods of pain relief are available if
the epidural fails.
Headaches Minor headaches are common after surgery, with
or without an epidural.
Occasionally a severe headache occurs after an epidural
because the lining of the fluid filled space surrounding the
spinal cord has been inadvertently punctured (a dural tap ).



The fluid leaks out and causes low pressure in the brain,
particularly when you sit up. Occasionally it may be necessary
to inject a small amount of your own blood into your epidural
space. This is called an epidural blood patch . The blood clots
and plugs the hole in the epidural lining. It is almost always
immediately effective. The procedure is otherwise the same as
for a normal epidural. For more information please see
Headache after an epidural or spinal anaesthetic .
Uncommon complications
Slow breathing. Some drugs used in the epidural can cause
slow breathing and/or drowsiness requiring treatment.
Catheter infection. The epidural catheter can become
infected and may have to be removed. Antibiotics may be
necessary. It is very rare for the infection to spread any further
than the insertion site in the skin.
Rare or very rare complications
Other complications, such as convulsions (fits), breathing
difficulty and temporary nerve damage are rare whilst
permanent disabling nerve damage, epidural abscess, epidural
haematoma (blood clot) and cardiac arrest (stopping of the
heart) are very rare indeed.
In comparison, you are more likely to die from an accident on
the roads or in your own home every year than suffer
permanent damage from an epidural. These risks can be
discussed further with your anaesthetist and more detailed
information is available.
(All risks quoted are approximate and assume best practice).



What if I decide not to have an epidural?
It is your choice. You do not have to have an epidural.
l There are several alternative methods of pain relief with
morphine that work well; injections given by the nurses or by
a pump into a vein which you control by pressing a button
(Patient Controlled Analgesia, PCA ).
l There are other ways in which local anaesthetics can be
given.
l You may be able to take pain relieving drugs by mouth.
l Every effort will always be made to ensure your comfort.

How do I ask further questions?
l Ask the nursing staff or your anaesthetist.
l Future sources of information about epidural anaesthesia
available from the website. www.youranaesthetic.info.
l Most hospitals have a team of nurses and anaesthetists who
specialise in pain relief after surgery. You can ask to see a
member of the pain team at any time. They may have leaflets
available about pain relief.



Useful organisations

Royal College of Anaesthetists
48-49 Russell Square
London WC1B 4JY.
Phone: + 44 20 7813 1900
Fax: + 44 20 7813 1876
E-mail:info@rcoa.ac.uk
Website: www.rcoa.ac.uk
The organisation responsible for the standards in
anaesthesia, critical care and pain management
throughout the UK.

Association of Anaesthetists of Great Britain
and Ireland
21 Portland Place
London WC1B 1PY
Phone: +44 20 7631 1650
Fax: +44 20 7631 4352
E-mail: info@aagb.org
Website: www.aagbi.org
This organisation works to promote the development of
anaesthesia and the welfare of anaesthetists and their patients
in Great Britain and Ireland.



Questions you may like to ask your anaesthetist
Q Who will give my anaesthetic?
Q Do I have to have this type of pain relief?
Q Have you often used this type of pain relief?
Q What are the risks of this type of pain relief?
Q Do I have any special risks?
Q How will I feel afterwards?

Tell us what you think Second edition March 2003

We welcome any suggestions to improve
this booklet. You should send these to:
The Patient Information Unit,
48 Russell Square, The Association of Anaesthetists
of Great Britain and Ireland (AAGBI)
London WC1B 4JY
E-mail: admin@youranaesthetic.info

The Royal College of Anaesthetists (RCA)

© The RCA and AABGI agree to the copying of this document for the purpose of producing local leaflets in the
United Kingdom and Ireland. Please quote where you have taken the information from. The Patient Information
Unit must agree to any changes if the AAGBI and RCA crests are to be kept.


Patient Sticker


APPENDIX 5 ENHANCED RECOVERY PROGRAMME
EVENING POST-SURGERY
FLUID BALANCE AND URINE

FREE ORAL FLUIDS Record On Fluid Chart
TOTAL FLUID INTAKE 2000ML
IV MAINTENANCE Record On Fluid Chart
Hourly Catheter Measurements
Record on Fluid Chart
Maintain 0.3 ml/kg/h (Ave. over 4 hours) IF LESS, INFORM DOCTOR

CHEST
Oxygen
Promote Deep Breathing Exercises
Encourage Cough

MOBILITY
(commence 6 hours post-op)
Out Of Bed For 2 Hours Circulatory Exercises
Ted Stockings

NUTRITION
High Protein Drink 1 High Protein Drink 2

REMEMBER: PATIENT IS ALLOWED FREE ORAL FLUIDS

PAIN AND NAUSEA

Epidural In-Situ Yes / No Effective Yes / No
Antiemetic Prescribed As Necessary
Post-op Assessment Pain Team

STOMA CARE
Inspect Stoma for good circulation
Ensure the patient has a good fitting, drainable appliance

TODAY S GOALS ACHIEVED? Yes / NO IF NO, REASON .

...................................................................................................................................................

SIGNATURE Date


Patient Sticker

DAY 1 POST-SURGERY

GENERAL MANAGEMENT
Ted Stockings Dalteparin

IF LESS, INFORM DOCTOR
Maintain 0.3 ml/kg/h (Ave. over 4 hours)

CHEST
Oxygen
Encourage Cough

MOBILITY
Out Of Bed For 8 Hours IF NOT ACHIEVED, WHY?
............................................
...................................
Ambulate x 2
............................................
...................................
Circulatory Exercises

NUTRITION

PAIN AND NAUSEA

Epidural In-Situ Yes / No Effective Yes / No
Antiemetic Prescribed As Necessary
Post-op Assessment Pain Team

STOMATHERAPY
The patient is encouraged to look at the Stoma
Pouch emptying procedure is explained including the use of Velcro fastener
Renew the pouch
Reassurance given regarding colour, odour, etc

TODAY S GOALS ACHIEVED? YES / NO IF NO, REASON ..........................................

..

SIGNATURE Date .


Patient Sticker

DAY 2 POST-SURGERY

GENERAL MANAGEMENT
Nutrition Stomatherapy Goals



CHEST
Oxygen
Physiotherapist Assess

MOBILITY
IF NOT ACHIEVED, WHY?
Out of bed for 8 hours
Ambulate x 4 6

NUTRITION
High Protein Drink 2
High Protein Drink 1

BREAKFAST .......................................... DINNER ...............................
SNACKS ..............................
LUNCH ...................................................

PAIN
Epidural Stopped Today If no, why? ................................
Oral Analgesia Prescribed Contra-indication .......................
(Paracetamol + NSAID or Tramadol if NSAID contra-indicated)
STOMA CARE
Patient is emptying pouch
Reassurance given regarding the appearance of the stoma. This may be a little
unsightly/oedematous at this time
Complete pouch change explained and undertaken

TODAY S GOALS ACHIEVED? YES / NO IF NO, REASON ..

..

SIGNATURE . Date


Patient Sticker

DAY 3 POST-SURGERY

GENERAL MANAGEMENT
CHECK DISCHARGE ARRANGEMENTS HAVE BEEN ADDRESSED


STOP IV MAINTENANCE IF POSSIBLE
RECTAL RESECTIONS: Remove Urethral Catheter if epidural/PCA down

CHEST
Physiotherapist Assessment

MOBILITY
Self caring IF NOT ACHIEVED, WHY?
............................................
Out Of Bed For 8 Hours
...................................
Ambulate x 6
...................................

NUTRITION


LUNCH ................................................... SNACKS ..............................

PAIN
Epidural stopped Oral Analgesia Prescribed

TODAY S GOALS ACHIEVED? YES / NO IF NO, REASON.........................................
................................................................................................................................................

FIT FOR DISCHARGE? YES / NO IF NO, REASON .....................................................

...............................................................................................

SIGNATURE . Date


Patient Sticker

DAY 4 POST-SURGERY

GENERAL MANAGEMENT
)
IS PATIENT FIT FOR DISCHARGE? YES / NO (If No, reason


FREE ORAL FLUIDS Record on Fluid Chart
IV MAINTENANCE SHOULD BE STOPPED
CATHETER SHOULD BE OUT

CHEST

MOBILITY
Out Of Bed For 8 Hours ............................................
...................................
Ambulate x 6
...................................
Limb Exercises

NUTRITION
LUNCH ................................................... SNACKS ..............................

PAIN
Oral Analgesia Prescribed

STOMA
· The patient should be participating in the pouch change procedure
· The patient will need to change their chosen pouch daily for practice and to become
confident the patient may have chosen an appliance prior to admission
· Explanation of the changing nature of output should be given

TODAY S GOALS ACHIEVED? YES / NO. IF NO, REASON ...........................
......................................................................................................................................
FIT FOR DISCHARGE? YES / NO IF NO, REASON ................................................

.....................................................................................................................................

SIGNATURE .. Date


Patient Sticker

DAY 5 POST-SURGERY

GENERAL MANAGEMENT
IS PATIENT FIT FOR DISCHARGE? YES / NO (If No, reason )


IV MAINTENANCE SHOULD BE STOPPED

CHEST

MOBILITY
............................................
Out Of Bed For 8 Hours
...................................
Ambulate x 6
...................................
Limb Exercises

NUTRITION

LUNCH ................................................... SNACKS ..............................

PAIN
Oral Analgesia Prescribed

STOMA CARE
The patient should be: - Changing the pouch unaided in the bathroom
- Disposing of soiled pouch and contents
- Be aware of methods of obtaining supplies
The patient should have knowledge of: - Skin care
- Complications that may occur
- Dietary implications
- The effect of medication on stoma output

TODAY S GOALS ACHIEVED? YES / NO IF NO, REASON ..........................................................
..................................................................................................................................................................
FIT FOR DISCHARGE? YES / NO IF NO, REASON ................................ .

SIGNATURE .. Date ..



APPENDIX 6

Day of operation
Epidural
Fentonyl and
Bupivocaine
Regular IV Paracetamol

1st post operative day
Epidural and regular IV
Paracetamol

2nd post operative day Evening of 2nd post
Epidural and regular operative consider
oral Paracetamol commencing NSAID
and PPI

3rd post operative day
Prescribe PRN doses of Contraindications to
Buscopan 20mg IV first suspend epidural for 6 NSAIDS
line (100mg maximum in hours at 8.00 am, give >Heart Failure
24 h ours) Morphine 10 regular Paracetamol >Renal Failure
mgs sc/po >GI Bleed
>Proven allergy to
NSAIDS

Recommence epidural if
pain score is <3/10 for
If contraindications
further 24 hours
commencing Codeine
administering loading
or Tramadol
doses prior to this. Give
regular Paracetamol and
consider NSAID and PPI

4th post operative day
suspend epidural for 6
hours and repeat pain
assessment



APPENDIX 7 - PONV FLOW CH ART

PONV Routine
Score ÞÞ Observations
NO
1 or 2

YES

1. CYCLIZINE 25-50MG
If given IV administer slowly over 3-5mins

Review in 1 hr

PONV
Score
1 or 2
Routine
Observations
1.1.1. Y 1.1. NO
E
S
Contraindicated with patients
with Parkinson s disease.
PROCHLOPERAZINE BUCCAL
3 - 6mg 12 hourly prn
Max. 12mg / 24 hours
Review in 1 hour
PONV Routine
Score Observation
1.1.2. NO Consider regular Cyclizine and
1 or 2
PRN Prochloperazine

· Consider referral to senior medical cover, anaesthetist
or acute pain nurse
· Reconsider causes ?abdominal obstruction
· Ondansetron 4 - 8mg IV/Oral


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